Provider Demographics
NPI:1578686929
Name:SCHWADERER, ADAM R (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:R
Last Name:SCHWADERER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:4700 SCHAEFER RD.
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031382183500000X
MI51010166182085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No183500000XPharmacy Service ProvidersPharmacist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00944850OtherRRMC
MI1578686929Medicaid
MI0D46002027Medicare PIN